Basic Information
| Provider Information | |||||||||
| NPI: | 1881793644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3309 E MULBERRY CT | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474012425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123312709 | ||||||||
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| Practice Location | |||||||||
| Address1: | RR #1 BOX 1000 | ||||||||
| Address2: | GREENE COUNTY GENERAL | ||||||||
| City: | LINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474419457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128472281 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01038810A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000594833 | 01 | IN | BLUE SHIELD | OTHER | 100468280 D | 05 | IN | MEDICAID |